Long-Term Experience With a Mandatory Clinical Decision Rule and Mandatory d-Dimer in the Evaluation of Suspected Pulmonary Embolism.

Abstract

This study evaluated the long-term effectiveness of mandatory assignment of both a clinical decision rule (CDR) and highly sensitive d-dimer in the evaluation of patients with suspected pulmonary embolism (PE). Institutional guidelines with a CDR and highly sensitive d-dimer were embedded in an order entry menu with mandatory assignment of key components before ordering a CT pulmonary angiogram (CTPA). Data were retrospectively extracted from the electronic health record. This was a retrospective review of 1,003 CTPA studies (905 patients, 845 male and 60 female patients, age 63.7 ± 13.5 years). CTPAs were positive for PE in 170 studies (17%), representing an average yield of 15% (year [average]; 2007 [15%], 2008 [18%], 2009 [15%], 2010 [15%], 2011 [17%], 2012 [15%], 2013 [23%]). The increased yield represented efforts of mandatory order entry assignments, educational sessions, and clinical champions. Different d-dimer thresholds with or without age adjustments in combination with the CDR identified about 10% of patients who may have been managed without CTPA. Mandatory assignment of a CDR and highly sensitive d-dimer clinical decision pathway can be successfully incorporated into an order entry menu and produce a sustained increase in CTPA yield of patients with suspected PE.